Which question is the most appropriate for the nurse to use to start the health history assessment?

Choice A reason: This is the correct choice because the nurse checks if the hospital policy allows the licensed practical nurse to perform venipuncture before delegating the task is an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By checking the hospital policy, the nurse ensures that the task is within the scope of practice and competency of the licensed practical nurse and that the delegation is consistent with the standards of care.

Choice B reason: This is an incorrect choice because the nurse confirms that the patient’s urine output is entered into the medical record by the nursing assistant by the end of the shift is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By confirming the documentation, the nurse is performing a quality check, but not providing supervision of the delegated task.

Choice C reason: This is an incorrect choice because the nurse ensures that the scale is accurate before directing the nursing assistant to obtain the patient’s weight is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By ensuring the accuracy of the scale, the nurse is preparing the equipment, but not providing supervision of the delegated task.

Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to ambulate the patient at least 20 feet in the hallway using the gait belt before lunch is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By directing the nursing assistant, the nurse is assigning the task, but not providing supervision of the delegated task.

Choice A reason: This is an incorrect choice because health-seeking behaviors related to expressed desire for better sleep is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Health-seeking behaviors are actions that a person takes to improve their health and well-being. However, this is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.

Choice B reason: This is an incorrect choice because impaired bed mobility related to presence of CPAP mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Impaired bed mobility is the limitation of the patient's ability to move in bed. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.

Choice C reason: This is an incorrect choice because risk for impaired skin integrity related to tight-fitting mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for impaired skin integrity is the potential for the patient's skin to be damaged or broken. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.

Choice D reason: This is the correct choice because risk for powerlessness related to inability to breathe regularly during sleep is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for powerlessness is the potential for the patient to feel a loss of control or self-efficacy. This is the most urgent and life-threatening problem for the patient, as it can result in psychological distress, anxiety, depression, or hopelessness.